Form CMS-10545 OASIS-D Item Set

Outcome and Assessment Information Set (OASIS-D) (CMS-10545)

Attachment B_508_OASIS_E_AllItems

Medicare and Medicaid OASIS Collection Requirements (Data Collection)

OMB: 0938-1279

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1279 can be found here:

2023-01-09 - No material or nonsubstantive change to a currently approved collection

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PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is XXXX-XXXX. The expiration date is XX/XX/XXXX. The time required to complete this information
collection is estimated to be XX minutes (XX minutes per data element), including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. This estimate does not include time for training. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact XXXX National Coordinator, Home Health
Quality Reporting Program Centers for Medicare & Medicaid Services.

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OUTCOME ASSESSMENT INFORMATION SET VERSION E (OASIS-E)
All Items
Section A

Administrative Information

M0018. National Provider Identifier (NPI) for the attending physician who has signed the plan of care

M0010. CMS Certification Number
M0014. Branch State

M0016. Branch ID Number

M0020. Patient ID Number

M0030. Start of Care Date

M0032. Resumption of Care Date

M0040. Patient Name

M0050. Patient State of Residence

M0060. Patient ZIP Code

M0064. Social Security Number

M0063. Medicare Number

M0065. Medicaid Number

M0069. Gender
Enter
Code

1. Male
2. Female

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M0066. Birth Date

A1005. Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
↓

Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E. Yes, another Hispanic, Latino, or Spanish origin
X. Patient unable to respond
Y. Patient declines to respond

A1010. Race
What is your race?
↓

Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E. Chinese
F. Filipino
G. Japanese
H. Korean
I.
Vietnamese
J.
Other Asian
K. Native Hawaiian
L. Guamanian or Chamorro
M. Samoan
N. Other Pacific Islander
X. Patient unable to respond
Y. Patient declines to respond
Z. None of the above

M0150. Current Payment Sources for Home Care
↓

Check all that apply
0. None; no charge for current services
1. Medicare (traditional fee-for-service)
2. Medicare (HMO/managed care/Advantage plan)
3. Medicaid (traditional fee-for-service)
4. Medicaid (HMO/managed care)
5. Workers' compensation
6. Title programs (for example, Title III, V, or XX)
7. Other government (for example, TriCare, VA)
8. Private insurance
9. Private HMO/managed care
10. Self-pay
11. Other (specify)
UK. Unknown

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A1110. Language
Enter Code

What is your preferred language?

Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

M0080. Discipline of Person Completing Assessment
Enter Code

1.
2.
3.
4.

RN
PT
SLP/ST
OT

M0090. Date Assessment Completed

M0100. This Assessment is Currently Being Completed for the Following Reason
Enter Code

Start/Resumption of Care
1. Start of care – further visits planned
3. Resumption of care (after inpatient stay)
Follow-Up
4. Recertification (follow-up) reassessment
5. Other follow-up
Transfer to an Inpatient Facility
6. Transferred to an inpatient facility – patient not discharged from agency
7. Transferred to an inpatient facility – patient discharged from agency
Discharge from Agency – Not to an Inpatient Facility
8. Death at home
9. Discharge from agency

M0906. Discharge/Transfer/Death Date
Enter the date of the discharge, transfer, or death (at home) of the patient.

M0102. Date of Physician-ordered Start of Care (Resumption of Care)
If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health
services, record the date specified.

M0104. Date of Referral
Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA.

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M0110. Episode Timing
Is the Medicare home health payment episode, for which this assessment will define a case mix group, an “early” episode or a
“later” episode in the patient’s current sequence of adjacent Medicare home health payment episodes?
Enter Code

1.
2.
UK
NA

Early
Later
Unknown
Not Applicable: No Medicare case mix group to be defined by this assessment.

A1250. Transportation (NACHC ©)
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
C. No
X. Patient unable to respond
Y. Patient declines to respond
Adapted from: NACHC© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health
Organizations, Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use
by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part or whole without written consent from
NACHC.
↓

M1000. From which of the following Inpatient Facilities was the patient discharged within the past 14 days?
↓

Check all that apply
1. Long-term nursing facility (NF)

2. Skilled nursing facility (SNF/TCU)
3. Short-stay acute hospital (IPPS)
4. Long-term care hospital (LTCH)
5. Inpatient rehabilitation hospital or unit (IRF)
6. Psychiatric hospital or unit
7. Other (specify)

NA Patient was not discharged from an inpatient facility ➔ Skip to B0200, Hearing at SOC,
Skip to B1300, Health Literacy at ROC

M1005. Inpatient Discharge Date (most recent)

M2301. Emergent Care
At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency
department (includes holding/observation status)?
Enter Code

0.
1.
2.
UK

No ➔ Skip to M2410, Inpatient Facility
Yes, used hospital emergency department WITHOUT hospital admission
Yes, used hospital emergency department WITH hospital admission
Unknown ➔ Skip to M2410, Inpatient Facility

M2310. Reason for Emergent Care
For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)?
↓

Check all that apply
1. Improper medication administration, adverse drug reactions, medication side effects, toxicity, anaphylaxis
10. Hypo/Hyperglycemia, diabetes out of control
19. Other than above reasons
UK Reason unknown

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M2410. To which Inpatient Facility has the patient been admitted?
Enter Code

1.
2.
3.
4.
NA

Hospital
Rehabilitation facility
Nursing home
Hospice
No inpatient facility admission [Omit “NA” option on TRN]

M2420. Discharge Disposition
Where is the patient after discharge from your agency? (Choose only one answer.)
Enter Code

Patient remained in the community (without formal assistive services) ➔ Skip to A2123, Provision of Current Reconciled
Medication List to Patient at Discharge
2. Patient remained in the community (with formal assistive services) ➔ Continue to A2121, Provision of Current
Reconciled Medication List to Subsequent Provider at Discharge
3. Patient transferred to a non-institutional hospice ➔ Continue to A2121, Provision of Current Reconciled Medication List
to Subsequent Provider at Discharge
4. Unknown because patient moved to a geographic location not served by this agency ➔ Skip to A2123, Provision of
Current Reconciled Medication List to Patient at Discharge
UK Other unknown ➔ Skip to A2123, Provision of Current Reconciled Medication List to Patient at Discharge
1.

A2120. Provision of Current Reconciled Medication List to Subsequent Provider at Transfer
At the time of transfer to another provider, did your agency provide the patient’s current reconciled medication list to the
subsequent provider?
Enter Code

0.
1.
2.

No – Current reconciled medication list not provided to the subsequent provider ➔ Skip to J1800, Any Falls Since
SOC/ROC
Yes – Current reconciled medication list provided to the subsequent provider ➔ Continue to A2122, Route of Current
Reconciled Medication List Transmission to Subsequent Provider
NA – The agency was not made aware of this transfer timely ➔ Skip to J1800, Any Falls Since SOC/ROC

A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
At the time of discharge to another provider, did your agency provide the patient’s current reconciled medication list to the
subsequent provider?
Enter Code

0.
1.

No – Current reconciled medication list not provided to the subsequent provider ➔ Skip to B1300, Health Literacy
Yes – Current reconciled medication list provided to the subsequent provider ➔ Continue to A2122. Route of Current
Reconciled Medication List Transmission to Subsequent Provider

A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Route of Transmission
A.

Electronic Health Record

Health Information Exchange

Verbal (e.g., in-person, telephone, video conferencing)

Paper-based (e.g., fax, copies, printouts)

Other Methods (e.g., texting, email, CDs)

↓

Check all that apply

↓

After completing A2122, Skip to B1300, Health Literacy at Discharge

A2123. Provision of Current Reconciled Medication List to Patient at Discharge
At the time of discharge, did your agency provide the patient’s current reconciled medication list to the patient, family and/or
caregiver?
Enter Code

0.
1.

No– Current reconciled medication list not provided to the patient, family, and/or caregiver ➔ Skip to B1300, Health
Literacy
Yes – Current reconciled medication list provided to the patient, family, and/or caregiver ➔ Continue to A2124, Route
of Current Reconciled Medication List Transmission to Patient.

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A2124. Route of Current Reconciled Medication List Transmission to Patient
Indicate the route(s) of transmission of the current reconciled medication list to the patient, family, and/or caregiver.
Route of Transmission
↓
A.

Electronic Health Record

Health Information Exchange

Verbal (e.g., in-person, telephone, video conferencing)

Paper-based (e.g., fax, copies, printouts)

Other Methods (e.g., texting, email, CDs)

Section B

Check all that apply

↓

Hearing, Speech, and Vision

B0200. Hearing
Enter Code

B1000. Vision
Enter Code

Ability to hear (with hearing aid or hearing appliances if normally used)
0. Adequate – no difficulty in normal conversation, social interaction, listening to TV
1. Minimal difficulty – difficulty in some environments (e.g., when person speaks softly, or setting is noisy)
2. Moderate difficulty – speaker has to increase volume and speak distinctly
3. Highly impaired – absence of useful hearing

Ability to see in adequate light (with glasses or other visual appliances)
0. Adequate – sees fine detail, such as regular print in newspapers/books
1. Impaired – sees large print, but not regular print in newspapers/books
2. Moderately impaired – limited vision; not able to see newspaper headlines but can identify objects
3. Highly impaired – object identification in question, but eyes appear to follow objects
4. Severely impaired – no vision or sees only light, colors or shapes; eyes do not appear to follow objects

B1300. Health Literacy (From Creative Commons ©)
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your
doctor or pharmacy?
Enter Code

0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
7. Patient declines to respond
8. Patient unable to respond
The Single Item Literacy Screener is licensed under a Creative Commons Attribution Noncommercial 4.0 International License.

Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all patients.
Enter Code

0.
1.

No (patient is rarely/never understood) ➔ Skip to C1310, Signs and Symptoms of Delirium (from CAM ©)
Yes ➔ Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code

Ask patient: “I am going to say three words for you to remember. Please repeat the words after I have said all three. The

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C0200. Repetition of Three Words

words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the patient's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of
furniture"). You may repeat the words up to two more times.

C0300. Temporal Orientation (Orientation to year, month, and day)
Enter Code

Enter Code

C0400. Recall
Enter Code

Enter Code

Ask patient: "Please tell me what year it is right now."
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct
Ask patient: "What month are we in right now?"
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days
Ask patient: "What day of the week is today?"
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct

Ask patient: "Let's go back to an earlier question. What were those three words that I asked you to repeat?"
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall “sock”
0. No – could not recall
1. Yes, after cueing ("something to wear")
2. Yes, no cue required
B. Able to recall “blue”
0. No – could not recall
1. Yes, after cueing ("a color")
2. Yes, no cue required
C. Able to recall “bed”
0. No – could not recall
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required

C0500. BIMS Summary Score
Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the patient was unable to complete the interview

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C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.
A. Acute Onset of Mental Status Change
Enter Code

Is there evidence of an acute change in mental status from the patient's baseline?
0. No
1. Yes

Coding:
0. Behavior not present
1. Behavior continuously present,
does not fluctuate
2. Behavior present, fluctuates
(comes and goes, changes in
severity)

↓ Enter Codes in Boxes
B. Inattention – Did the patient have difficulty focusing attention, for example, being
easily distractible or having difficulty keeping track of what was being said?

Disorganized thinking – Was the patient's thinking disorganized or incoherent
(rambling or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject)?
D. Altered level of consciousness – Did the patient have altered level of consciousness,
as indicated by any of the following criteria?

vigilant – startled easily to any sound or touch

lethargic – repeatedly dozed off when being asked questions, but responded to
voice or touch

stuporous – very difficult to arouse and keep aroused for the interview

comatose – could not be aroused
Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program,
LLC. Not to be reproduced without permission.
C.

M1700. Cognitive Functioning
Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for
simple commands.
Enter Code

0.
1.
2.
3.
4.

Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.
Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.
Requires assistance and some direction in specific situations (for example, on all tasks involving shifting of attention)
or consistently requires low stimulus environment due to distractibility.
Requires considerable assistance in routine situations. Is not alert and oriented or is unable to shift attention and
recall directions more than half the time.
Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.

M1710. When Confused
(Reported or Observed Within the Last 14 Days):
Enter Code

0.
1.
2.
3.
4.
NA

Never
In new or complex situations only
On awakening or at night only
During the day and evening, but not constantly
Constantly
Patient nonresponsive

M1720. When Anxious
(Reported or Observed Within the Last 14 Days):
Enter Code

0.
1.
2.
3.
NA

None of the time
Less often than daily
Daily, but not constantly
All of the time
Patient nonresponsive

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Section D

Mood

D0150. Patient Mood Interview (PHQ-2 to 9)
Say to patient: "Over the last 2 weeks, have you been bothered by any of the following problems?"

If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
1.
2.
Symptom
Symptom
0. No (enter 0 in column 2)
0. Never or 1 day
Presence
Frequency
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
9. No response (leave column
2. 7-11 days (half or more of the days)
↓ Enter Scores in ↓
2 blank).
3. 12-14 days (nearly every day)
Boxes
A.

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the PHQ interview.
C.

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself – or that you are a failure or have let yourself or your family down

G. Trouble concentrating on things, such as reading the newspaper or watching television
H. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so
fidgety or restless that you have been moving around a lot more than usual
I.

Thoughts that you would be better off dead, or of hurting yourself in some way

D0160. Total Severity Score
Enter Score

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27. Enter 99 if
unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items)

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code

0.
1.
2.
3.
4.
7.
8.

Never
Rarely
Sometimes
Often
Always
Patient declines to respond
Patient unable to respond

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Section E

Behavior

M1740. Cognitive, Behavioral, and Psychiatric Symptoms that are demonstrated at least once a week (Reported or Observed):
↓ Check all that apply
1. Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24 hours,
significant memory loss so that supervision is required
2. Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop activities,
jeopardizes safety through actions
3. Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc.
4. Physical aggression: aggressive or combative to self and others (for example, hits self, throws objects, punches,
dangerous maneuvers with wheelchair or other objects)
5. Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)
6. Delusional, hallucinatory, or paranoid behavior
7. None of the above behaviors demonstrated

M1745. Frequency of Disruptive Behavior Symptoms (Reported or Observed):
Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.
Enter Code

0.
1.
2.
3.
4.
5.

Section F

Never
Less than once a month
Once a month
Several times each month
Several times a week
At least daily

Preferences for Customary Routine Activities

M1100. Patient Living Situation
Which of the following best describes the patient's residential circumstance and availability of assistance?

Living Arrangement

Around the
Clock

Availability of Assistance
Occasional/
Regular
Regular
Short-Term
Daytime
Nighttime
Assistance
↓ Check one box only ↓

No Assistance
Available

Patient lives alone

Patient lives with other person(s) in the
home

Patient lives in congregate situation (for
example, assisted living, residential care
home)

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SOC/ROC
M2102. Types and Sources of Assistance
Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to
provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.
Enter Code

Supervision and safety (due to cognitive impairment)
0. No assistance needed – patient is independent or does not have needs in this area
1. Non-agency caregiver(s) currently provide assistance
2. Non-agency caregiver(s) need training/supportive services to provide assistance
3. Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance
4. Assistance needed, but no non-agency caregiver(s) available

Discharge
M2102. Types and Sources of Assistance
Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to
provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.
Enter Code

Enter Code

Section G

ADL assistance (for example, transfer/ambulation, bathing, dressing, toileting, eating/feeding)
0. No assistance needed – patient is independent or does not have needs in this area
1. Non-agency caregiver(s) currently provide assistance
2. Non-agency caregiver(s) need training/supportive services to provide assistance
3. Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance
4. Assistance needed, but no non-agency caregiver(s) available
Medication administration (for example, oral, inhaled, or injectable)
0. No assistance needed – patient is independent or does not have needs in this area
1. Non-agency caregiver(s) currently provide assistance
2. Non-agency caregiver(s) need training/supportive services to provide assistance
3. Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance
4. Assistance needed, but no non-agency caregiver(s) available
Medical procedures/treatments (for example, changing wound dressing, home exercise program)
0. No assistance needed – patient is independent or does not have needs in this area
1. Non-agency caregiver(s) currently provide assistance
2. Non-agency caregiver(s) need training/supportive services to provide assistance
3. Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance
4. Assistance needed, but no non-agency caregiver(s) available
Supervision and safety (due to cognitive impairment)
0. No assistance needed – patient is independent or does not have needs in this area
1. Non-agency caregiver(s) currently provide assistance
2. Non-agency caregiver(s) need training/supportive services to provide assistance
3. Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance
4. Assistance needed, but no non-agency caregiver(s) available

Functional Status

M1800. Grooming
Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth
or denture care, or fingernail care).
Enter Code

0.
1.
2.
3.

Able to groom self unaided, with or without the use of assistive devices or adapted methods.
Grooming utensils must be placed within reach before able to complete grooming activities.
Someone must assist the patient to groom self.
Patient depends entirely upon someone else for grooming needs.

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M1810. Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, frontopening shirts and blouses, managing zippers, buttons, and snaps.
Enter Code

0.
1.
2.
3.

Able to get clothes out of closets and drawers, put them on and remove them from the upper body without
assistance.
Able to dress upper body without assistance if clothing is laid out or handed to the patient.
Someone must help the patient put on upper body clothing.
Patient depends entirely upon another person to dress the upper body.

M1820. Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or
nylons, shoes.
Enter Code

0.
1.
2.
3.

Able to obtain, put on, and remove clothing and shoes without assistance.
Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.
Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.
Patient depends entirely upon another person to dress lower body.

M1830. Bathing
Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).
Enter Code

0.
1.
2.

3.
4.
5.
6.

Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of the
tub/shower.
Able to bathe in shower or tub with the intermittent assistance of another person:
a. for intermittent supervision or encouragement or reminders, OR
b. to get in and out of the shower or tub, OR
c. for washing difficult to reach areas.
Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for
assistance or supervision.
Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink,
in chair, or on commode.
Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on
commode, with the assistance or supervision of another person.
Unable to participate effectively in bathing and is bathed totally by another person.

M1840. Toilet Transferring
Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
Enter Code

0.
1.
2.
3.
4.

Able to get to and from the toilet and transfer independently with or without a device.
When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.
Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance).
Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.
Is totally dependent in toileting.

M1845. Toileting Hygiene
Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet,
commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.
Enter Code

0.
1.
2.
3.

Able to manage toileting hygiene and clothing management without assistance.
Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for
the patient.
Someone must help the patient to maintain toileting hygiene and/or adjust clothing.
Patient depends entirely upon another person to maintain toileting hygiene.

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M1850. Transferring
Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
Enter Code

0.
1.
2.
3.
4.
5.

Able to independently transfer.
Able to transfer with minimal human assistance or with use of an assistive device.
Able to bear weight and pivot during the transfer process but unable to transfer self.
Unable to transfer self and is unable to bear weight or pivot when transferred by another person.
Bedfast, unable to transfer but is able to turn and position self in bed.
Bedfast, unable to transfer and is unable to turn and position self.

M1860. Ambulation/Locomotion
Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.
Enter Code

0.
1.

2.
3.
4.
5.
6.

Section GG

Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (specifically:
needs no human assistance or assistive device).
With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to independently walk on
even and uneven surfaces and negotiate stairs with or without railings.
Requires use of a two-handed device (for example, walker or crutches) to walk alone on a level surface and/or
requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.
Able to walk only with the supervision or assistance of another person at all times.
Chairfast, unable to ambulate but is able to wheel self independently.
Chairfast, unable to ambulate and is unable to wheel self.
Bedfast, unable to ambulate or be up in a chair.

Functional Abilities and Goals

GG0100. Prior Functioning: Everyday Activities

Indicate the patient’s usual ability with everyday activities prior to the current illness, exacerbation, or injury.
Coding:
↓ Enter Codes in Boxes
3. Independent – Patient completed all the
A. Self Care: Code the patient’s need for assistance with bathing, dressing,
activities by themself, with or without an
using the toilet, and eating prior to the current illness, exacerbation, or
assistive device, with no assistance from a
injury.
helper.
B. Indoor Mobility (Ambulation): Code the patient’s need for assistance
2. Needed Some Help – Patient needed partial
with walking from room to room (with or without a device such as cane,
assistance from another person to complete
crutch or walker) prior to the current illness, exacerbation, or injury.
any activities.
C. Stairs: Code the patient’s need for assistance with internal or external
1. Dependent – A helper completed all the
stairs (with or without a device such as cane, crutch, or walker) prior to
activities for the patient.
the current illness, exacerbation, or injury.
8. Unknown
D. Functional Cognition: Code the patient’s need for assistance with
9. Not Applicable
planning regular tasks, such as shopping or remembering to take
medication prior to the current illness, exacerbation, or injury.

GG0110. Prior Device Use

Indicate devices and aids used by the patient prior to the current illness, exacerbation, or injury.
↓ Check all that apply
A. Manual wheelchair
B. Motorized wheelchair and/or scooter
C. Mechanical lift
D. Walker
E. Orthotics/Prosthetics
Z. None of the above

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SOC/ROC
GG0130. Self-Care
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was not attempted at
SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10 or 88 is
permissible to code discharge goal(s).
Coding:

Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or of poor quality, score according
to amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent – Patient completes the activity by themself with no assistance from a helper.
05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the
activity.
04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less
than half the effort.
02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than
half the effort.
01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more
helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
Patient refused
Not applicable – Not attempted and the patient did not perform this activity prior to the current illness, exacerbation or injury.
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
Not attempted due to medical condition or safety concerns
1.
2.
SOC/ROC
Discharge
Performance
Goal
↓ Enter Codes in Boxes ↓
07.
09.
10.
88.

A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food
and/or liquid once the meal is placed before the patient.
B. Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert
and remove dentures into and from mouth, and manage denture soaking and rinsing with use of
equipment.
C. Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or
having a bowel movement. If managing an ostomy, include wiping the opening but not managing
equipment.
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing
of back and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not
include footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is
appropriate for safe mobility; including fasteners, if applicable.

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Follow-up
GG0130. Self-Care
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was not attempted at FollowUp, code the reason.
Coding:

Patient refused
Not applicable – Not attempted and the patient did not perform this activity prior to the current illness, exacerbation or injury.
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
Not attempted due to medical condition or safety concerns

4.
Follow-Up
Performance
Enter Codes
in Boxes

↓

A.
B.
C.

Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once
the meal is placed before the patient.
Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from mouth, and manage denture soaking and rinsing with use of equipment.
Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment.

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Discharge
GG0130. Self-Care
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was not attempted at
Discharge, code the reason.
Coding:

3.
Discharge
Performance
Enter Codes
in Boxes
↓

A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once
the meal placed before the patient.
B. Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment.
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and
hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate
for safe mobility; including fasteners, if applicable.

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SOC/ROC
GG0170. Mobility
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was not attempted at
SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10 or 88 is
permissible to code discharge goal(s).
Coding:

Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.

Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of
the bed with no back support.
Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the
side of the bed.

D.
E.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).

Toilet transfer: The ability to get on and off a toilet or commode.

Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not
include the ability to open/close door or fasten seat belt.
Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If SOC/ROC performance is coded 07, 09, 10 or 88, ➔Skip to GG0170M, 1 step (curb)

I.
J.
K.

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces
(indoor or outdoor), such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb or up and down one step.
If SOC/ROC performance is coded 07, 09, 10 or 88, ➔ Skip to GG0170P, Picking up object.
N. 4 steps: The ability to go up and down four steps with or without a rail.
If SOC/ROC performance is coded 07, 09, 10 or 88, ➔ Skip to GG0170P, Picking up object.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
L.

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SOC/ROC GG0170. Mobility – Continued
1.
SOC/ROC
Performance

2.
Discharge
Goal

Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such
as a spoon, from the floor.
Q. Does patient use wheelchair and/or scooter?
0. No ➔ Skip to M1600, Urinary Tract Infection
1. Yes ➔Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50
feet and make two turns.
RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a
corridor or similar space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

Follow-up
GG0170. Mobility
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was not attempted at
Follow-Up code the reason.
Coding:

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Follow-up
GG0170. Mobility
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was not attempted at
Follow-Up code the reason.
4.
Follow-up
Performance
Enter Codes in Boxes

↓

Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the
bed.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.

Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no
back support.
Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the
bed.

D.
E.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).

Toilet transfer: The ability to get on and off a toilet or commode.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If Follow-Up performance is coded 07, 09, 10 or 88 ➔Skip to GG0170M, 1 step (curb).

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.

4 steps: The ability to go up and down four steps with or without a rail.
Does patient use wheelchair and/or scooter?
0. No ➔Skip to M1033, Risk for Hospitalization
1. Yes ➔ Continue to GG0170R, Wheel 50 feet with two turns
Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make
two turns.
Q.

Discharge
GG0170. Mobility
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was not attempted at
Discharge, code the reason.
Coding:

Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or of poor quality, score according
to amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent – Patient completes the activity by themself with no assistance from a helper.
05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the
activity.
04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less
than half the effort.
02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than
half the effort.
01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more
helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness, exacerbation or injury.
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Discharge
GG0170. Mobility
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was not attempted at
Discharge, code the reason.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

3.
Discharge
Performance
Enter Codes
in Boxes

↓
A.

Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.

Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back
support.

Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).

Toilet transfer: The ability to get on and off a toilet or commode.

Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to
open/close door or fasten seat belt.
Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If Discharge performance is coded 07, 09, 10 or 88, ➔Skip to GG0170M, 1 step (curb).

I.
J.
K.

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor),
such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb or up and down one step.
If Discharge performance is coded 07, 09, 10 or 88, ➔ Skip to GG0170P, Picking up object.
N. 4 steps: The ability to go up and down four steps with or without a rail.
If Discharge performance is coded 07, 09, 10 or 88, ➔Skip to GG0170P, Picking up object.
L.

12 steps: The ability to go up and down 12 steps with or without a rail.

Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from
the floor.
Q. Does patient use wheelchair and/or scooter?
0. No ➔ Skip to M1600, Urinary Tract Infection
1. Yes ➔ Continue to GG0170R, Wheel 50 feet with two turns
Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two
turns.
RR3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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Section H

Bladder and Bowel

M1600. Has this patient been treated for a Urinary Tract Infection in the past 14 days?
Enter Code

0.
1.
NA
UK

No
Yes
Patient on prophylactic treatment
Unknown [Omit “UK” option on DC]

M1610. Urinary Incontinence or Urinary Catheter Presence
Enter Code

0.
1.
2.

No incontinence or catheter (includes anuria or ostomy for urinary drainage)
Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or suprapubic)

M1620. Bowel Incontinence Frequency
Enter Code

0.
1.
2.
3.
4.
5.
NA
UK

Very rarely or never has bowel incontinence
Less than once weekly
One to three times weekly
Four to six times weekly
On a daily basis
More often than once daily
Patient has ostomy for bowel elimination
Unknown [Omit “UK” option on DC]

M1630. Ostomy for Bowel Elimination
Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay;
or b) necessitated a change in medical or treatment regimen?
Enter Code

Section I

0.
1.
2.

Patient does not have an ostomy for bowel elimination.
Patient's ostomy was not related to an inpatient stay and did not necessitate change in medical or treatment regimen.
The ostomy was related to an inpatient stay or did necessitate change in medical or treatment regimen.

Active Diagnoses

M1021. Primary Diagnosis & M1023. Other Diagnoses
Column 1

Diagnoses (Sequencing of diagnoses should reflect the seriousness of each
condition and support the disciplines and services provided)

Column 2

ICD-10-CM and symptom control rating for each condition. Note that the
sequencing of these ratings may not match the sequencing of the diagnoses

M1021. Primary Diagnosis
a.

___________________________________

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M1023. Other Diagnoses
b.

___________________________________

M1028. Active Diagnoses – Comorbidities and Co-existing Conditions
↓

Check all that apply
1. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
2. Diabetes Mellitus (DM)
3. None of the above

Section J

Health Conditions

M1033. Risk for Hospitalization
Which of the following signs or symptoms characterize this patient as at risk for hospitalization?
↓

Check all that apply
1. History of falls (2 or more falls – or any fall with an injury – in the past 12 months)
2. Unintentional weight loss of a total of 10 pounds or more in the past 12 months
3. Multiple hospitalizations (2 or more) in the past 6 months
4. Multiple emergency department visits (2 or more) in the past 6 months
5. Decline in mental, emotional, or behavioral status in the past 3 months
6. Reported or observed history of difficulty complying with any medical instructions (for example, medications,
diet, exercise) in the past 3 months
7. Currently taking 5 or more medications
8. Currently reports exhaustion
9. Other risk(s) not listed in 1-8
10. None of the above

J0510. Pain Effect on Sleep
Enter Code

Ask patient: "Over the past 5 days, how much of the time has pain made it hard for you to sleep at night"
0. Does not apply – I have not had any pain or hurting in the past 5 days ➔ Skip to M1400, Short of Breath at SOC/ROC; Skip
to J1800, Any Falls Since SOC/ROC at DC
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

J0520. Pain Interference with Therapy Activities
Enter Code

Ask patient: "Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to
pain?”

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J0520. Pain Interference with Therapy Activities
0.
1.
2.
3.
4.
8.

Does not apply – I have not received rehabilitation therapy in the past 5 days
Rarely or not at all
Occasionally
Frequently
Almost constantly
Unable to answer

J0530. Pain Interference with Day-to-Day Activities
Enter Code

Ask patient: "Over the past 5 days, how often you have limited your day-to-day activities (excluding rehabilitation therapy
sessions) because of pain?"
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

J1800. Any Falls Since SOC/ROC, whichever is more recent
Enter Code

Has the patient had any falls since SOC/ROC, whichever is more recent?
0. No ➔ Skip to M1400, Short of Breath at DC; Skip to M2005, Medication Intervention at TRN and DAH
1. Yes ➔Continue to J1900, Number of Falls Since SOC/ROC

J1900. Number of Falls Since SOC/ROC, whichever is more recent

Coding:
0. None
1. One
2. Two or more

↓ Enter Codes in Boxes
A. No injury: No evidence of any injury is noted on physical assessment by the nurse
or primary care clinician; no complaints of pain or injury by the patient; no change
in the patient's behavior is noted after the fall
B. Injury (except major): Skin tears, abrasions, lacerations, superficial bruises,
hematomas, and sprains; or any fall-related injury that causes the patient to
complain of pain
C. Major injury: Bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma

M1400. When is the patient dyspneic or noticeably Short of Breath?
Enter Code

0.
1.
2.
3.
4.

Section K

Patient is not short of breath
When walking more than 20 feet, climbing stairs
With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet)
With minimal exertion (for example, while eating, talking, or performing other ADLs) or with agitation
At rest (during day or night)

Swallowing/Nutritional Status

M1060. Height and Weight – While measuring, if the number is X.1-X.4 round down; X.5 or greater round up.
inches
pounds

Height (in inches). Record most recent height measure since the most recent SOC/ROC

Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to
standard agency practice (for example, in a.m. after voiding, before meal, with shoes off, etc.)

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SOC/ROC
K0520. Nutritional Approaches

1. On Admission
Check all of the nutritional approaches that apply on admission

1.
On Admission
Check all that apply

Parenteral/IV feeding

B.
C.
D.

Feeding tube (e.g., nasogastric or abdominal (PEG))
Mechanically altered diet – require change in texture of food or liquids
(e.g., pureed food, thickened liquids)
Therapeutic diet (e.g., low salt, diabetic, low cholesterol)

None of the above

Discharge
K0520. Nutritional Approaches
4.
5.

Last 7 days
Check all of the nutritional approaches that were received in the last 7 days
At discharge
Check all of the nutritional approaches that were being received at discharge

Parenteral/IV feeding

B.
C.
D.

None of the above

↓

4.
5.
Last 7 days
At discharge
↓
Check all that apply
↓

M1870. Feeding or Eating
Current ability to feed self meals and snacks safely. Note: This refers only to the process of eating, chewing, and swallowing, not
preparing the food to be eaten.
Enter Code

0.
1.

2.
3.
4.
5.

Section M

Able to independently feed self.
Able to feed self independently but requires:
a. meal set-up; OR
b. intermittent assistance or supervision from another person; OR
c. a liquid, pureed, or ground meat diet.
Unable to feed self and must be assisted or supervised throughout the meal/snack.
Able to take in nutrients orally and receives supplemental nutrients through a nasogastric tube or gastrostomy.
Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.
Unable to take in nutrients orally or by tube feeding.

Skin Conditions

M1306. Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable?
(Excludes Stage 1 pressure injuries and all healed pressure ulcers/injuries)
Enter Code

0.
1.

No ➔ Skip to M1322, Current Number of Stage 1 Pressure Injuries at SOC/ROC; Skip to M1324, Stage of Most Problematic
Unhealed Pressure Ulcer/Injury that is Stageable at DC
Yes

M1307. The Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2 pressure ulcers)
Enter Code

1.
2.

Was present at the most recent SOC/ROC assessment
Developed since the most recent SOC/ROC assessment. Record date pressure ulcer first identified:

NA No Stage 2 pressure ulcers are present at discharge

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SOC/ROC
M1311. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

Enter Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough.
May also present as an intact or open/ruptured blister.
Number of Stage 2 pressure ulcers
B1. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may
be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Number of Stage 3 pressure ulcers
C1. Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of
the wound bed. Often includes undermining and tunneling.
Number of Stage 4 pressure ulcers
D1. Unstageable: Non-removable dressing/device: Known but not stageable due to non-removable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device

Enter Number

E1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar

Enter Number

F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury

Discharge
M1311. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

Enter Number
Enter Number

Enter Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough.
May also present as an intact or open/ruptured blister.
Number of Stage 2 pressure ulcers – If 0 ➔Skip to M1311B1, Stage 3
A2. Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC

B1. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may
be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Number of Stage 3 pressure ulcers – If 0 ➔Skip to M1311C1, Stage 4
B2. Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC

C1. Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of
the wound bed. Often includes undermining and tunneling.
Number of Stage 4 pressure ulcers – If 0 ➔Skip to M1311D1, Unstageable: Non-removable dressing/device
C2. Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC

D1. Unstageable: Non-removable dressing/device: Known but not stageable due to non-removable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device – If 0 ➔Skip to M1311E1,
Unstageable: Slough and/or eschar
D2. Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
E1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar – If 0 ➔Skip to M1311F1,
Unstageable: Deep tissue injury
E2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury – If 0 ➔Skip to M1324, Stage of Most
Problematic Unhealed Pressure Ulcer/Injury that is Stageable
F2. Number of these unstageable pressure injuries that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC

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Page 26 of 32

M1322. Current Number of Stage 1 Pressure Injuries
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have
a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues.
Enter Code

0
1
2
3
4 or more

M1324. Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable
Excludes pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough
and/or eschar, or deep tissue injury.
Enter Code

1.
2.
3.
4.
NA

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries

M1330. Does this patient have a Stasis Ulcer?
Enter Code

0.
1.
2.
3.

No ➔Skip to M1340, Surgical Wound
Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY
Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing/device) ➔
Skip to M1340, Surgical Wound

M1332. Current Number of Stasis Ulcer(s) that are Observable
Enter Code

1.
2.
3.
4.

One
Two
Three
Four or more

M1334. Status of Most Problematic Stasis Ulcer that is Observable
Enter Code

1.
2.
3.

Fully granulating
Early/partial granulation
Not healing

M1340. Does this patient have a Surgical Wound?
Enter Code

0.
1.
2.

No ➔Skip to N0415, High-Risk Drug Classes: Use and Indication
Yes, patient has at least one observable surgical wound
Surgical wound known but not observable due to non-removable dressing/device ➔ Skip to N0415, High-Risk Drug
Classes: Use and Indication

M1342. Status of Most Problematic Surgical Wound that is Observable
Enter Code

0.
1.
2.
3.

Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

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Section N

Medications

SOC/ROC and Discharge
N0415. High-Risk Drug Classes: Use and Indication
1.

Is taking
Check if the patient is taking any medications by pharmacological
classification, not how it is used, in the following classes

Indication noted
If Column 1 is checked, check if there is an indication noted for all
medications in the drug class
Antipsychotic

Anticoagulant

Antibiotic

Opioid

Antiplatelet

Hypoglycemic (including insulin)

None of the Above

1. Is Taking
2. Indication Noted
↓
Check all that apply
↓

M2001. Drug Regimen Review
Did a complete drug regimen review identify potential clinically significant medication issues?
Enter Code

0.
1.
9.

No – No issues found during review ➔ Skip to M2010, Patient/Caregiver High-Risk Drug Education
Yes – Issues found during review
NA – Patient is not taking any medications ➔ Skip to O0110, Special Treatments, Procedures, and Programs

M2003. Medication Follow-up
Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete
prescribed/recommended actions in response to the identified potential clinically significant medication issues?
Enter Code

0.
1.

No
Yes

M2005. Medication Intervention
Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?
Enter Code

0.
1.
9.

No
Yes
NA – There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any
medications

M2010. Patient/Caregiver High-Risk Drug Education
Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics,
anticoagulants, etc.) and how and when to report problems that may occur?
Enter Code

0. No
1. Yes
NA Patient not taking any high-risk drugs OR patient/caregiver fully knowledgeable about special precautions associated
with all high-risk medications

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M2020. Management of Oral Medications
Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage
at the appropriate times/intervals. Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or
willingness.)
Enter Code

Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.
Able to take medication(s) at the correct times if:
a. individual dosages are prepared in advance by another person; OR
b. another person develops a drug diary or chart.
2. Able to take medication(s) at the correct times if given reminders by another person at the appropriate times
3. Unable to take medication unless administered by another person.
NA No oral medications prescribed.
0.
1.

M2030. Management of Injectable Medications
Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of
correct dosage at the appropriate times/intervals. Excludes IV medications.
Enter Code

Able to independently take the correct medication(s) and proper dosage(s) at the correct times.
Able to take injectable medication(s) at the correct times if:
a. individual syringes are prepared in advance by another person; OR
b. another person develops a drug diary or chart.
2. Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the
injection
3. Unable to take injectable medication unless administered by another person.
NA No injectable medications prescribed.
0.
1.

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Page 29 of 32

Section O

Special Treatment, Procedures, and Programs

SOC/ROC
O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.

a. On Admission
Check all that apply
↓

Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Mid-line
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the Above

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Discharge
O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.

c. At Discharge
Check all that apply
↓

Cancer Treatments
A1. Chemotherapy
A2 IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Mid-line
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the Above

M1041. Influenza Vaccine Data Collection Period
Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?
Enter Code

0.
1.

No ➔ Skip to M2401, Intervention Synopsis
Yes ➔ Continue to M1046, Influenza Vaccine Received

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M1046. Influenza Vaccine Received
Did the patient receive the influenza vaccine for this year’s flu season?
Enter Code

1.
2.
3.
4.
5.
6.
7.
8.

Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)
Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)
Yes; received from another health care provider (for example, physician, pharmacist)
No; patient offered and declined
No; patient assessed and determined to have medical contraindication(s)
No; not indicated – patient does not meet age/condition guidelines for influenza vaccine
No; inability to obtain vaccine due to declared shortage
No; patient did not receive the vaccine due to reasons other than those listed in responses 4-7.

M2200. Therapy Need
In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is
the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech-language pathology
visits combined)? (Enter zero [“000”] if no therapy visits indicated.)

Section Q

Participation in Assessment and Goal Setting

M2401. Intervention Synopsis
At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the
physician-ordered plan of care AND implemented? (Mark only one box in each row.)
Plan/Intervention

No
Yes
↓Check only one box in each row↓

Falls prevention interventions

Depression intervention(s) such as
medication, referral for other
treatment, or a monitoring plan
for current treatment

Intervention(s) to monitor and
mitigate pain

Intervention(s) to prevent
pressure ulcers

Pressure ulcer treatment based on
principles of moist wound healing

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Not Applicable
Every standardized, validated multi-factor fall risk
assessment conducted at or since the most recent
SOC/ROC assessment indicates the patient has no risk for
falls.
Patient has no diagnosis of depression AND every
standardized, validated depression screening conducted at
or since the most recent SOC/ROC assessment indicates the
patient has: 1) no symptoms of depression; or 2) has some
symptoms of depression but does not meet criteria for
further evaluation of depression based on screening tool
used.
Every standardized, validated pain assessment conducted
at or since the most recent SOC/ROC assessment indicates
the patient has no pain.
Every standardized, validated pressure ulcer risk
assessment conducted at or since the most recent
SOC/ROC assessment indicates the patient is not at risk of
developing pressure ulcers.
Patient has no pressure ulcers OR has no pressure ulcers
for which moist wound healing is indicated.

Page 32 of 32

File Type	application/pdf
File Title	OUTCOME ASSESSMENT INFORMATION SET VERSION E (OASIS-E)
Subject	CMS, OASIS-E, Home Health
Author	Centers for Medicare & Medicaid Services
File Modified	2022-04-13
File Created	2022-04-10